Ward Parkway Presbyterian Preschool Registration
2017-2018 School Year
7406 Ward Parkway – Kansas City, MO 64114
(816) 361-2201
PLEASE READ – IMPORTANT INSTRUCTIONS
You must print out the entire Preschool Enrollment Packet from your computer and fill it out completely and
bring it when registering your child for the 2017-2018 school year. Each child registering for Preschool
must have their own completed enrollment packet!
Ward Parkway Preschool Enrollment Checklist
______ Enrollment Policy – read only
______ Enrollment Form – (2 pages)
______ Health Form – Must be complete and turned in at the Get Acquainted Conference in the fall.
______ Authorization for Emergency Medical Care
______ Personal Questionnaire
______ Authorization for Child Pick-Up
______ Family History
______Office Emergency Form
______Photo Release Form (Good for 3 years)
2017-2018 Enrollment Form
Please enter the year that you (the parent), or your first child started attending Ward
Parkway Preschool _____________
Identifying Information About this Child:
Boy _______ Girl _______
Child’s Name: ______________________________ Birthdate: ____________
Name child wants to be called ____________
Address _______________________________________________________
Street
Home Phone: (___)______________
City
Zip Code
Email Address:___________________________________________________
Mother’s Name: _________________________________________________
Address: ______________________________________________________
Street
City
Zip Code
Home Phone: (___)________Pager: (___)_________Cell Phone(___)_________
Employed By: _________________ Days of Employment ______________
Hours of Employment_______to_____
Address:_____________________________ Work Phone: (___)___________
Father’s Name: _________________________________________________
Address: ______________________________________________________
Street
City
Zip Code
Home Phone: (___)________Pager: (___)_________Cell Phone(___)_________
Employed By: _________________ Days of Employment ______________
Hours of Employment_______to_____
Address:_____________________________ Work Phone: (___)__________
Emergency Contacts other than parents or Doctor:
Name: _________________________________ Phone: (___)____________
Address: ______________________________________________________
Street
City
Zip Code
Name: _________________________________ Phone: (___)____________
Address: ______________________________________________________
Street
City
Zip Code
To be completed by Ward Parkway Preschool:
Admission Date: _____________________________________________
Days: M T W TH F
Hours: ______________________
Discharge Date: ______________________________________________
2017-2018 Enrollment Form – Page #2
Please mark your 1st and 2nd choices from the following classes
Pre–K Classes :
(born Summer 2012 – August 2013)
Blue Room 4 Days: Monday, Tuesday, Wednesday, Thursday 9 a.m. -2:30 p.m.
Green Room - 3 Days: Tuesday, Wednesday, Thursday 9 a.m. - 2:30 p.m.
Yellow Room - 3 Days: Tuesday, Wednesday, Thursday 9 a.m. - 2:30 p.m.
$516.00 monthly _____
$387.00 monthly _____
$387.00 monthly _____
Preschool 2 Classes: (born September 2013 – August 2014)
Gold Room 3 Days: Tuesday, Wednesday, Thursday 9 a.m. - 2:30 p.m.
Purple Room - 2 Days: Monday & Wednesday 9 a.m. - 2:30 p.m.
Purple Room - 2 Days: Tuesday & Thursday 9 a.m. - 2:30 p.m.
$387.00 monthly _____
$258.00 monthly _____
$258.00 monthly _____
Preschool 1 Classes: (born September 2014 – February 2015)
Orange Room - 2 - 1/2 days weekly: Monday & Wednesday - 9:00 - 12:00 p.m
Orange Room - 2 - 1/2 days weekly: Tuesday & Thursday - 9:00 - 12:00 p.m.
$129.00 monthly _____
$129.00 monthly _____
Enrollment Fee - $75.00 (non-refundable)
PLUS 1 month’s tuition (May 2018)
(Enrollment Fee includes a group class picture.)
Payment attached:
Enrollment Fee ______________
Check # _____________
May 2018 Tuition ____________
Total amount paid_____________
Cash ________________
Before / After Care will begin the second week of Preschool.
Financial Policy: If cancellation becomes necessary before June 15th, one – half of your tuition will be returned to you.
After June 15th, NO REFUNDS will be made.
Late tuition: If monthly tuition is 2 months delinquent, you must either pay or present a letter of intent to the
preschool. If neither is received, the child’s enrollment will be terminated.
“I understand and agree to abide by the above financial policy” ________________________________
Parent or Guardian
“I would like my child to be enrolled in Ward Parkway Preschool for the school year 2017 – 2018. I hereby give my
permission for this child to participate in all preschool activities, in the building, on the grounds around the building, on
the playground, and on all teacher-chaperoned hikes in the neighborhood. I understand that if I choose to dis-enroll
from the program, before the end of the school year, a 30 day notice is required.”
___________________________
Date
_________________________________________________
Parent or Guardian
Ward Parkway Presbyterian Preschool
7406 Ward Parkway
Kansas City, MO
64114
2017 – 2018 Health Form
To be completed and signed by a Physician
Child’s Name: _________________________________________
Date of Birth: __________
Name of Parents (or Guardian): _______________________________________________________
Home Telephone (_____) ________________________
Work Telephone (_____) ____________
Name of Child’s Physician: ________________________
Telephone (_____) _________________
Dates of ALL Immunizations (Month, Day, Year)
DTP / DT
#1
#2
#3
#4
#5
____________
____________
____________
____________
____________
MMR
__________ HIB
__________
__________
_____
_____
_____
_____
_____
_____
_____
Influenza
Frequent Colds
Ear Infections
Sinusitis
Eye Infection
Tonsillitis
Tuberculosis
OPV
#1
#2
#3
#4
____________
____________
____________
____________
PCV
#1
#2
#3
#4
#5
____________
____________
____________
____________
____________
__________ Hepatitis B (HB)
__________
__________ Varicella
__________
__________
__________
TB
__________
__________
__________ Hepatitis A
__________
__________
Record of Illness: Please make a single “x” to indicate any disease or condition your child has had, and a double “xx” to
indicate if it has occurred in the past 3 months.
_____
_____
_____
_____
_____
_____
_____
Chicken Pox
Scarlet Fever
Appendicitis
Anemia
Hernia
Heart Disease
Poison Ivy
_____
_____
_____
_____
_____
_____
_____
Hay Fever
_____
Asthma
_____
Hives
_____
Fever Blisters
_____
Pinworm
_____
Skin Disease
_____
Bee Sting Allergy _____
Allergies
Kidney Disease
Bone Disease
Rheumatic Fever
Epilepsy
Cerebral Palsy
Other
Allergies Child Might Have:
Special Medical Condition / Anything Medically Teachers should be aware of:
Medication child is taking now:
Purpose for medication(s):
Restrictions Necessary for this Child’s Care:
“ I have examined this child and know the above medical information to be correct”
__________________________
Date
______________________________
Signature of Physician
(or Registered Nurse under supervision of child’s physician)
Authorization For Emergency Medical Care
Physician and Preferred Hospital to be used in an Emergency
(PLEASE FILL OUT INFORMATION COMPLETELY INCLUDING COMPLETE
STREET ADDRESS, CITY, & ZIP CODE)
I understand that in case of an accident or injury to my child, I will be notified immediately. If my
child requires emergency medical care, the physician and preferred hospital to be used are:
Doctor / Clinic: ________________________________________________
Address: __________________________Telephone (_____) ___________
Street
City
Zip
Preferred Hospital: _____________________________________________
Address: __________________________Telephone (_____) ___________
Street
City
Zip
I also understand that in case of a life-threatening emergency, my child will be taken by ambulance
(911) to the nearest appropriate hospital.
Agreements: (Please Read and Initial)
* I have been informed of the required health and safety inspections and understand that
inspection forms are available for review.”
________
(Please Initial)
* I have been informed of the ILLNESS PROCEDURE. It is printed in the Parent Handbook on
pages 9 and 10. When my child is ill, I understand that my child will not be accepted for care.
________
(Please Initial)
____________________________________________
Parent / Legal Guardian Signature
_________________
Date
2017-2018 Personal Questionnaire
We believe your child is a miracle in the process of becoming what God wants him/her to be. We
also believe each child coming to our preschool is very special and the only one of his kind. For this
reason, we would like for you to think about the following questions, answer them and return this
questionnaire to your child’s teachers. From this, they will get to know your child better, and will
be able to work with you as a team to guide your child in his/her growth and development.
Name of child: __________________________ Birthdate: ______________________
Name your child wants to be called: __________________________________________
Was this child premature? _____________________ If so, how much? _____________
Mother’s Name: __________________
Occupation: __________________________
Father’s Name: __________________
Occupation: __________________________
Names and ages of any siblings: _____________________________________________
Does your child have opportunities to play with children his/her age? _________________
What activities does your child like to do best? _________________________________
What activities does your child like to do least? _________________________________
What are your child’s regular responsibilities at home? ____________________________
Does your child have any pets? ______________________________________________
Does your child have any allergies? ___________________________________________
Does your child have any fears? _____________________________________________
Has your child had any serious illnesses or injuries? ______________________________
Can others understand your child’s speech? ____________________________________
Have you noticed any hearing problems? _______________________________________
What is your child’s bedtime during school? ____________________________________
What does your child like to eat for snack? ____________________________________
What food(s) does your child NOT like or CANNOT eat? __________________________
Has your child had any previous children’s group experiences, such as Sunday School,
Parent’s Day Out, or Preschool? If so, where? __________________________________
_____________________________________________________________________
Is your child enrolled in any other children’s groups this year? If so, where? ___________
_____________________________________________________________________
Has your child had any behavioral or cognitive screenings that might enable us to
better help him/her? _____________________________________________________
What are your expectations for your child this preschool year? _____________________
_____________________________________________________________________
What other information about your child would be helpful to us as your child’s teachers?
_____________________________________________________________________
Child Pick-Up Authorization
2017-2018
The following people have my approval and permission to pick up my child,
_________________________ from preschool on the following days:
Day of the week
______________
______________
______________
______________
______________
Pick-up driver
______________
______________
______________
______________
______________
Phone #
_________
_________
_________
_________
_________
Other authorized drivers that might be picking up my child during the year are:
Pick-up Driver
______________
______________
______________
______________
Phone #
_________
_________
_________
_________
Please DO NOT release my child to the following individual(s) after or during preschool:
Name
Description
______________
_______________________
______________
_______________________
If anyone, other than those listed above will be picking up my child at preschool, I will send a
written message to the classroom teachers, or call the preschool office.
I understand that my child will not be released to anyone whose name is NOT on this list. I will
keep this form updated if changes occur during the school year.
_____________________________
Parent or Legal Guardian
_________
Date
2017-2018 Office Emergency Form
Identifying Information About this Child:
Boy _______ Girl _______
Child’s Name: ______________________________ Birthdate: ___________
Address _______________________________________________________
Street
City
Zip Code
Home Phone: (___)______________
Mother’s Name: _________________________________________________
Home Phone: (___)________Cell Phone(___)________Work Phone:(__)________
Father’s Name: _________________________________________________
Home Phone: (___)________Cell Phone(___)________Work Phone: (___)______
Emergency Contacts other than parents or Doctor:
Name: _________________________________ Phone: (___)____________
Address: ______________________________________________________
Street
City
Zip Code
Name: _________________________________ Phone: (___)____________
Address: ______________________________________________________
Street
City
Zip Code
Authorization For Emergency Medical Care
Physician and Preferred Hospital to be used in an Emergency
(PLEASE FILL OUT INFORMATION COMPLETELY INCLUDING COMPLETE STREET
ADDRESS, CITY, & ZIP CODE)
I understand that in case of an accident or injury to my child, I will be notified immediately. If my
child requires emergency medical care, the physician and preferred hospital to be used are:
Doctor / Clinic: ________________________________________________
Address: __________________________Telephone (_____) ___________
Street
City
Zip
Street
City
Zip
Preferred Hospital: _____________________________________________
Address: __________________________Telephone (_____) ___________
I also understand that in case of a life-threatening emergency, my child will be taken by ambulance
(911) to the nearest appropriate hospital.
Parent Signature: ____________________________________ Date: _________
Ward Parkway Preschool
Student Name/Photo Release Form
As we participate in various school/community activities, we have opportunities to provide
photos of our students in newsworthy events. Photos may appear in the local newspaper, school promotions,
website*, and/or preschool brochures or fliers.
*We want to ensure the privacy and safety of all students. This site contains comprehensive information about the
preschool. (Names will not appear with pictures)
Conditions of use
· This form is valid for three years from the date you sign it. The consent will automatically expire after this time.
· We will not re-use any photographs after this time.
· We will not include personal e-mail, postal addresses, telephone or fax numbers on our website or in printed literature
advertising the preschool.
· We may use group or class photographs.
Please answer questions 1 to 4 below, then sign and date the form.
Please circle your answer
1. May we use your child’s image for promotional purposes?
Yes
I have read and understood the conditions of this form.
Student Name: _________________________________
Parent Name: ___________________________________
Parent Signature: ________________________________
Date: ____________
/
No
2017-2018 Family History Questionnaire
This questionnaire is part of our Preschool Family History / Multicultural Project. Please work with your child to fill in
the answers, and return this form to us at your “Get-Acquainted Conference”.
Child’s Full Name: _________________________________________________
1. I was born in____________________________________________________
City & State
2. My Mother’s name is _________________. She was born in_______________.
State or Country
3. My Father’s Name is__________________. He was born in_______________.
State or Country
4. My Mothers parents live (or lived) in__________________________________.
State or Country
They were born in ___________________and_______________________.
5. My Fathers parents live (or lived) in__________________________________.
State or Country
They were born in ___________________and_______________________.
6. Did my grandparents or great-grandparents come from another country?
Which person? ______________________________________________
Which country? _____________________________________________
7. What is my families cultural / ethnic heritage? _________________________
8. Does our family have special customs or traditions? What are they? _________
_______________________________________________________________
9. Are your parents willing to share any of these customs, traditions, stories of a
special relative, pictures or visuals with our class? _________________________